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NATAP: NYC PrEP/STIs-Club Drugs/Higher Odds of STI

in NYC - Club drug users had higher odds of reporting a bacterial STI compared with non-club drug users: results from a cross-sectional analysis of gay and bisexual men on HIV pre-exposure prophylaxis

"Overall, a quarter (26%, n=17) reported a BSTI [bacterial STI ]diagnosis in the prior 6 months; nearly half (42%) of club drug users had a BSTI compared with 9% of non-club drug users…..On average, men reported 5.1 sexual partners (SD=4.4) and 5.1 CAS acts (SD=5.4) in the past 30 days, and half (51%) of the sample reported recent engagement in club drug use (per study design)…..Nearly half (48%) were white, most (72%) had a bachelor’s degree or higher education, and most (79%) had annual income of $20 000 or more. Sixty-three per cent received their PrEP-related care from a primary care provider, and 62% reported not missing a PrEP dose in the past 90 days….Men with higher education and club drug users were more likely to report a recent BSTI in bivariate analyses. GBM who reported a higher number of CAS acts were also significantly more likely to report a BSTI diagnosis; however, the number of sexual partners and other variables analysed were not significantly associated with BSTI

In this study, GBM who engaged in club drug use and those who reported a
greater number of recent CAS acts were more likely to self-report a
BSTI diagnosis while on HIV PrEP. Of particular note, 42% of club drug
users reported a BSTI in the past 6 months. Based on this study and
previous research among PrEP users that identified comparable rates of
BSTIs,2
regular BSTI testing and risk-reduction counselling for PrEP users are
warranted. PrEP users who report club drug use and CAS are particularly
important for ongoing BSTI testing and counselling. Club drug use is one
mechanism to increase sexual arousal and motivations for sex,6 which could be uniquely enhanced with diminished concern about HIV with PrEP use.4
However, because club drug use is not an activity that causes
transmission of BSTIs in and of itself, we posit club drug users on PrEP
could be members of higher risk sexual networks.9 10
This hypothesis is supported by findings indicating higher engagement
in group sex activities among GBM and other MSM who combine drug and
PrEP use compared with those who only use PrEP.7
As such, healthcare providers providing PrEP and follow-up maintenance
care should initiate ongoing BSTI risk-reduction counselling with their
patients, particularly if they report club drug use and/or CAS
engagement.”

----------------------------

The objective of this study was to compare the prevalence of polydrug
use, use of drugs associated with chemsex, specific drug use, and
HIV-related behaviours, between two time periods , using two groups of
HIV-negative men who have sex with men (MSM) attending the same sexual
health clinics in London and Brighton, in two consecutive periods of
time from 2013 to 2016.

Results
In total, 991 MSM were included from AURAH and 1031 MSM from AURAH2.
After adjustment for sociodemographic factors, use of drugs associated
with chemsex had increased (adjusted PR (aPR) 1.30, 95% CI 1.11 to 1.53)
and there were prominent increases in specific drug use; in particular,
mephedrone (aPR 1.32, 95% CI 1.10 to 1.57),
γ-hydroxybutyric/γ-butryolactone (aPR 1.47, 95% CI 1.15 to 1.87) and
methamphetamine (aPR 1.42, 95% CI 1.01 to 2.01). Use of ketamine had
decreased (aPR 0.54, 95% CI 0.38 to 0.78). Certain measures of
HIV-related behaviours had also increased, most notably PEP use (aPR
1.50, 95% CI 1.21 to 1.88) and number of self-reported bacterial STI
diagnoses (aPR 1.24, 95% CI 1.08 to 1.43).

Conclusions
There have been significant increases in drug use associated with
chemsex and some measures of HIV-related behaviours among HIV-negative
MSM in the last few years. Changing patterns of drug use and associated
behaviours should be monitored to enable sexual health services to plan
for the increasingly complex needs of some clients.

Club drug users had higher odds
of reporting a bacterial STI compared with non-club drug users: results
from a cross-sectional analysis of gay and bisexual men on HIV
pre-exposure prophylaxis

Aug 2018

In a meta-analysis of literature published during August 2017, BSTIs were significantly higher among PrEP users pooled across eight studies reporting BSTI prevalence, with most studies in the overarching meta-analysis of 17 open-label and observational studies reporting evidence of an increase in condomless sex after PrEP uptake.3 These findings are supported by newer evidence indicating young MSM who used PrEP engaged in more receptive condomless anal sex (CAS) compared with those not taking PrEP,4 and although PrEP can protect against HIV it cannot protect against BSTIs. It is plausible that subgroups of PrEP users could be at a higher BSTI
risk, especially MSM who combine club drug use (ie, ketamine, MDMA
(3,4-methyl​enedioxy​methamphetamine)/ecstasy, GHB
(γ-hydroxybutyricacid), cocaine or methamphetamine) and PrEP.

Abstract

Objectives
Pre-exposure prophylaxis (PrEP) can reduce HIV transmission risk for
many gay, bisexual and other men who have sex with men. However,
bacterial STI (BSTI) associated with decreasing condom use among HIV
PrEP users is a growing concern. Determining the characteristics of
current PrEP users at highest BSTI risk fills a critical gap in the
literature.

MethodsGay and bisexual men (GBM) in New York City on HIV PrEP for 6 or more
months (n=65) were asked about chlamydia, gonorrhoea and syphilis
diagnoses in the past 6 months. By design, half (51%) of the sample were
club drug users. We examined the associations of length of time on
PrEP, type of PrEP care provider, PrEP adherence, number of sexual
partners, number of condomless anal sex acts and club drug use on
self-reported BSTI using multivariable, binary logistic regressions,
adjusting for age, race/ethnicity, education and income.

Results
Twenty-six per cent of GBM on HIV PrEP reported a diagnosis of BSTI in
the past 6 months. Men who reported club drug use (adjusted OR
(AOR)=6.60, p<0.05) and more frequent condomless anal sex in the past 30 days (AOR=1.13, p<0.05)
had higher odds of reporting a BSTI. No other variables were
significantly associated with self-reported BSTI in the multivariable
models.

Conclusions
Club drug users could be at a unique BSTI risk, perhaps because of
higher risk sexual networks. Findings should be considered preliminary,
but suggest the importance of ongoing BSTI screening and risk-reduction
counselling for GBM on HIV PrEP.

Introduction

HIV
pre-exposure prophylaxis (PrEP)—a once-daily oral pill of tenofovir
disoproxil fumarate/emtricitabine—greatly reduces HIV risk for many gay,
bisexual and other men who have sex with men (MSM).1 2
However, bacterial STIs (BSTIs) associated with decreasing condom use
among HIV PrEP users is a growing concern. In a meta-analysis of
literature published during August 2017, BSTIs were significantly higher
among PrEP users pooled across eight studies reporting BSTI prevalence,
with most studies in the overarching meta-analysis of 17 open-label and
observational studies reporting evidence of an increase in condomless
sex after PrEP uptake.3
These findings are supported by newer evidence indicating young MSM who
used PrEP engaged in more receptive condomless anal sex (CAS) compared
with those not taking PrEP,4 and although PrEP can protect against HIV it cannot protect against BSTIs.

It
is plausible that subgroups of PrEP users could be at a higher BSTI
risk, especially MSM who combine club drug use (ie, ketamine, MDMA
(3,4-methyl​enedioxy​methamphetamine)/ecstasy, GHB
(γ-hydroxybutyricacid), cocaine or methamphetamine) and PrEP. Club drugs
can be used by MSM to stimulate sex, particularly when used in
combinations (ie, ‘chemsex’), and are especially relevant to
‘party-n-play’ scenes often including group sex and condomless sex.5 6
Therefore, PrEP users engaging in club drug use could be at a higher
BSTI risk because of network prevalence resulting from partner
concurrency and condomless sex compared with their non-drug using
counterparts.7
With limited prior research on BSTI acquisition among PrEP users, we
sought to determine the characteristics of self-identified gay and
bisexual men (GBM) who had higher odds of self-reporting a BSTI
diagnosis while on daily oral PrEP for HIV prevention.

Methods

Data used for this analysis were taken from PrEP & Me, a study of 104 GBM who were active HIV PrEP users at the time of enrolment (see online supplementary appendix A for more details). GBM were recruited via targeted sampling8
in New York City from November 2015 to November 2016. Passive
recruitment strategies included posting advertisements on social media
and geosocial sexual networking apps, and active recruitment was
conducted by the research staff within gay-concentrated neighbourhoods and settings. To join the study, participants had to call our
office, whereby they were screened for eligibility and scheduled for an
appointment (if eligible). To be eligible for the study, participants
had to (1) be 18 years or older, (2) be cisgender male, (3) identify as
gay/bisexual, (4) have been taking HIV PrEP for at least 30 days, but
not via a research study that provided the PrEP medication, (5) reside
in the New York City area, and (6) have access to the internet. By
design of the parent study, half of the enrolled participants
self-reported club drug use (ketamine, MDMA/ecstasy, GHB, cocaine or
methamphetamine) in the past 30 days. The study was marketed as an
opportunity for participants to describe their experiences on PrEP, and
we did not mention club drug use in our advertising for the study. For
the purposes of this analysis, we excluded 39 GBM who were on PrEP for
less than 6 months.

Results

Sixty-five GBM who had been taking HIV PrEP for more than 6 months were included in this cross-sectional analysis (see online supplementary appendix A for more details); 59% had been on PrEP for 1 year or longer (see table 1). Men ranged in age between 21 and 61 years old (Mage=32
years). Nearly half (48%) were white, most (72%) had a bachelor’s
degree or higher education, and most (79%) had annual income of $20 000
or more. Sixty-three per cent received their PrEP-related care from a
primary care provider, and 62% reported not missing a PrEP dose in the
past 90 days.

On average, men reported 5.1 sexual partners (SD=4.4) and
5.1 CAS acts (SD=5.4) in the past 30 days, and half (51%) of the sample
reported recent engagement in club drug use (per study design). The
average club drug use was reported on 4.9 days (SD=4.5) among those
reporting using at least once in the past 30 days, and 82% of club drug
users reported using on more than 1 day. Overall, a quarter (26%, n=17)
reported a BSTI diagnosis in the prior 6 months; nearly half (42%) of
club drug users had a BSTI compared with 9% of non-club drug users.
Although we aggregated the three BSTIs for data analysis, the most
commonly reported BSTI was gonorrhoea (n=13), followed by chlamydia
(n=10) and syphilis (n=3).

Men with higher education and club drug users were more likely to report
a recent BSTI in bivariate analyses. GBM who reported a higher number
of CAS acts were also significantly more likely to report a BSTI
diagnosis; however, the number of sexual partners and other variables
analysed were not significantly associated with BSTI (see table 1).
After adjusting for age, race/ethnicity, education and income, club
drug users had higher odds of reporting a BSTI compared with non-users.
Men who had more CAS also had higher odds of reporting a recent BSTI
diagnosis. No significant differences in self-reported BSTI diagnosis
were observed by length of time on PrEP, type of PrEP-related care
provider, PrEP adherence or number of sexual partners (see table 1) (see online supplementary appendix A for supplemental analyses).

Discussion

In
this study, GBM who engaged in club drug use and those who reported a
greater number of recent CAS acts were more likely to self-report a BSTI
diagnosis while on HIV PrEP. Of particular note, 42% of club drug users
reported a BSTI in the past 6 months. Based on this study and previous
research among PrEP users that identified comparable rates of BSTIs,2
regular BSTI testing and risk-reduction counselling for PrEP users are
warranted. PrEP users who report club drug use and CAS are particularly
important for ongoing BSTI testing and counselling. Club drug use is one
mechanism to increase sexual arousal and motivations for sex,6 which could be uniquely enhanced with diminished concern about HIV with PrEP use.4
However, because club drug use is not an activity that causes
transmission of BSTIs in and of itself, we posit club drug users on PrEP
could be members of higher risk sexual networks.9 10
This hypothesis is supported by findings indicating higher engagement
in group sex activities among GBM and other MSM who combine drug and
PrEP use compared with those who only use PrEP.7
As such, healthcare providers providing PrEP and follow-up maintenance
care should initiate ongoing BSTI risk-reduction counselling with their
patients, particularly if they report club drug use and/or CAS
engagement.

Limitations

Our
findings should be understood in light of their limitations. First,
this study is based on retrospective recall data with differing recall
periods, and we are unable to determine temporality of events or
causality. Second, we rely on self-reported BSTI diagnosis data, which
could under-report the number of BSTIs because of asymptomatic or
unrecognised infections that went undiagnosed. Third, this was a small
sample size of PrEP users in New York City. It is likely that a larger
sample size might have identified additional significant differences.
Additional research is needed with larger samples of GBM on
PrEP—including club drug users on PrEP—with comparative samples of men
not on PrEP to determine heightened or comparable BSTI risk associated
with PrEP and/or club drug use.

Conclusion

Our
findings highlight the importance of ongoing BSTI screening and
risk-reduction counselling for GBM on HIV PrEP. Club drug users could be
at unique BSTI risk, perhaps because of higher risk sexual networks.
However, our data provide no means of establishing a causal link between
club drug use and BSTI acquisition, rather only a correlation. GBM
engaging in CAS more often are also important for frequent testing and
ongoing BSTI risk-reduction counselling.

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